\

-=---= S TUDENT NAME: \A.urox-·,e Goo~f~'i

Student Name:
Instructions for Students: Take a printed copy of this checklist to every lab, simulation, and clinical day. Ensure lab/simulation or clinical faculty verify
demonstration or observation of skills by signing and dating in the appropriate box. Scan a copy of the signed Psychomotor Skills Checklist and upload it
into the appropriate drop box in LoudCloud at the end of every didactic course with skills lab experiences and every clinical course.
Note: Students are responsible for maintaining the original signed copy of this checklist throughout the duration of the program. Uploading the
document into the appropriate courses is required to advance from semester to semester and to graduate. Students are not required to demonstrate
or observe every skill on this form in the clinical setting.

Instructions for Lab Faculty: Print, sign, and date below each skill to acknowledge the student's successful demonstration in the lab setting. Students
must be signed off by lab faculty for all required skills prior to demonstration in clinical.

Instructions for Clinicians: Sign and date in the appropriate box next to each skill to acknowledge the student's s~ccessful demonstration/ observation
of the skill. Students must be signed off by lab faculty on a required skills prior to demonstration in clinical. Students are not expected to observe or
demonstrate all listed skills in clinical, however, clinicians should look for opportunities for students to observe and demonstrate as many skills as
possible.
Student Signature and Date - Level 1: Student Signature and Date - level 2:

\7_/6/\~ V-v-- !1- ~ /i O/\y

By signing, I acknowledge that I have demonstrated or observed the skills By signing, I acknowledge that I have demonstrated or
indicated. observed the skills indicated.

Student Signature and Date - Level 3 Student Signature and Date - Level 4:

L jj__ 1oJ\1o11~
By signing, I acknowledge that I have demonstrated or observed the skills By signing, I acknowledge that I have demonstrated or
indicated. observed the skills indicated.

Skill checklists can be found in the textbook Clinical Nursing Skills and Techniques, 8th ed., by Perry, Potter, and Ostendorf
~C
Tll~
DENT ~~
NAME: - - -- - - - - . - - - - -~Settlng-
Clinical Setting -==-~ =
Lab Setting Student ~
Demoed
Lab Faculty Printed Name, Signature, and Date (Include below after
Clinician Printed Name, Signature, and Date or
student has successfully demonstrated each skill in lab.)
Observed

Required Level 1 Lab Skills-•these skills must be signed off in lab

prior to demonstration in clinical
Documentation and Informatics
• Giving a handoff report
D

~ li1 ki 0
•oocumenting nurses' progrt~s n9tes ..

-t · C{JJ1l. 5JIJ!(,, ~
D

C\ l} \ - :- ·-. r 0
• Adverse event/incident
D

°\ 'J \~ 0
Vital Signs
* Measuring body temperatur
. mYJ--&i reN u>jzz. /, 8
C D
Cb\tq\f6 m~,Qhl 11 /s /1B 0
* Assessing radial pulse
, lnSkr&l, RJJ ttJ/zz/t B D
1 t/sl,e
.mtJ\J-?d 0
• Ass sing apical puls
?a ,,r2AJ ,l/s)JB D

0
• Assessing respirations
~ &LL!ZJJ ,~1zz1,a D
\1-
q, q\ ff, Donna Carlson, MSN, R
1

fJ tlf s l 1& 0
• Assessing manual blood pressure
Y. ~
f()/zz1ts
i\J D

Donna Carlson MSN R ms,J-[dt r2N 101~ /1e 0

l-----,: E
~
,
E,-.J
l'.'.C\ms\e_ lxid((e'\
~;:sessing blood pressure electronically
c121J 11 Is 1e D
9121 )1" ~trJzi~ 0
*Measuring oxygen saturation (puls
D

Donna Carlson, MSN, R 0

*PBA - Vital Signs (Level 1}

~ ~m5U---rdlrw o/~/18
Health Assessment
*General survey 10 /22.lta D
~{2,0[1i ~~ JI /s )t'&. 0

' /lll::J.:r c'cl

I~ to /zrzlta D

, m~cd,,(21.J lI /s ]18 0

~ ,,,_ / II[/ , m::,J-cdt r&J' ~•l/5 )8 D

1
1 V'-' /I I 11 }Uo/l8 0
*Car iovascular assessment
ti/sits
~~~~~
D
11
Uc. /t B 0

., ,¼"'e D
0
n urologic assessment

~;C;J /~~}J-
1
"/2.z/28 D
8 0
*Monitoring intake and output
2 /y /\9 D

,~(.?ltt ~ , hl.J h '6 0

*PBA - Head-to-Toe Assessment (Level_1}
STUDENT NAME:
Medical Asepsis
*Hand hygiene
D

~\19\\\i
• Isolation precautions
Donna Carlson, MSN, Rf\' . /Ji311-fd, rztJ t'/s/1~ 0

0
Sterile Technique , RN
D

0
*Preparing a sterile field
D

o\ q \~ 0

•sterUe glovingO\\ f\\\~ D

0
Safe Patient Handling, Transfer and Positioning

ll/s Ita
*Using sa fe and effective transfer tech
D
0\ ~ \t onna Carls 0
* Moving and positioning _c lients in ~~ 1/1½/1'1 D

0\y:.,\ \t Donna Carlson MSN 0

e
Personal Care and Bed Making

•eathingacl~\~vi, ~
11JJ~ ID l1.- l'o D

0
*Perinea! care ( onna

c\ ~\\"i)
D

ti 2k>/tB 0

Donna Carlson, MSN, Rf\:

 D

0
*Care of dentures
D
~.__ ~ /4,,)i!,S) 9-1~-Jg
0
*Performing mouth care for unconscious/debilitated client
D

0
*Making an unoccupie bed ar; S ,~N
D

0
*Use of a urinal
D

JD 2l \i 0
*Making an occupied bed

9 S <[ Donna Carlson, MSN, RN

D

*Positioning client on a bedpan or fracture D

0
Oxygen Therapy
*Applying a nasal _cannula or oxyg
D

0
*Using incentive spir met ry
?>I\ , I 1ct D

lu IO \ i onna Carlson, MSN, RN 0

,.

STUDENT NAME:
Medication Administration
*Administering oral medications
D

1/28/1~ 0
*Administerin medications through an enteral feed· tu e

l\ \1- \ i
*Applying topica l medications to the skin
D

l/-Zg -13 , /zco1t9 0

*Instilling eye and ear medications

~ m:9J-U,tfl.J t/z.s/1e
1 D

0
*Administering nasal instillations
D

0
*Using metered-dose inhalers

~
D
11
~--~cl1/&.J /2a/;e 0
* Administering rectal suppositories
D
~ ~65~
0
Parenteral Medications
*Preparing injections: Ampules and vials

~ ~ m;w-&l, «JJ 1 2./s/,e D

0
*Administering intradermal injections
D

'Administering ~:bc;neou'JJ~ e I/ 28/I C\

0

0
 uO ENT NAME: \l.C>.ynn e \x-<l
fr~\j
*Administering intramuscular injections

I~ )5 )Ir ~ iJ!{)J f,/J f1.1)-(_ D

0
Therapeutic Use of Heat and Cold
* Applying heat
WlC D

0
Donna Carlson, MSN, RN
*Applying cold D

q l8 l~ 0

Specimen Collection

existing indwelling cat eter fl/ Mwzc e

*Urine specimen collection: Mids~m urine; Urine specimen from D

*Collecting a ti D

I &t/FJ}ZLe 0

D
arl gt,1,
on MSN,tr!
1l . _.,,,,
~
0
lt l t-\b\-l \ ~ 1/1'-1 /iO.,
*Urine screening fo gl D

0
0
Donna Carlson, MSN, R; J
STUDENT NAME:
Optional Additional Skills to Demonstrate in Clinical
Anytime During or After Level 1

Health Assessment
Genitalia and rectum assessment
D

Exercise and Ambulation

Performing range-of-motion exercises
, trl:J.J-zJ}. IZ}J II I:s },e D
4~~55,) 1I }v.:. )t~ 0

Applying elastic stocki; s :d sequ ~ 'i]Jfijt er✓:JJ:➔~i~::::::::::::::µ~~------~~~~- \.-j/\/\~ D

Y/\/1'-\ 0
Assisting with ambulatio
,RJJ uJ~l1s D
~ f , J i?Js,J (.Q I rclJ 1(J )1~} t8 0
Support Surfaces and Special Beds

\i: 7';pa::;,ms,1H'd,i6V ~ 9/4/4~ - - - - - - -- - - - - - ------J_Jo~ _J

0
Placing a client on an air-suspension or air-fluidized bed
D

0
Safety and Quality Improvement
Applying a P Y · al restraint
D

0
Pain Management and Basic Comfort M
Nonpharmacologic pain manag
1/z'o/19 D

Donna Carlson, MSN, RN 0

Providing p in relief
D

qho \ 1/zs/19 0
Care of the Eye and Ear
Eye care for nonresponsive clients
D

0
Care of hearing aids
D

0
Airway Management
Performing orophary
D

I /IY/ IC\ 0
Dressings and Bandages
Applying a dressing
D

0
Appl .
D

0
4

'
' D

0
STUDENT NAME:
Specimen Collection
Measuring occult blood in stool
&u~ e ~ - - - - - -0 -----1
0 Donna
Sputum Collection
D

0
Elimination
Emptying of ostomy ba D
0
• l l
Required Level 2 Lab S 1 1S-*these skills must be signed off in lab
prior to demonstration in clinical -On Insertion of an G Tube-in the required
section-Add peak flow as optional in level 2
Parenteral Medications
'Admini · i ~ b; Jenous bolus
D

0
*Admmisterin I ravenous medication by piggyback, intermittent
infusion sets, and · i-in sion pumps D

z/2,1/{q, _tll~ 'tN F1,tJJJ--L. 0

*PBA - Peripheral Intravenous Insertion (Level 2)

0
Urinary Elimination
*PBA - Foley Catheter Insertion (Level 2)
D

0
 ~ nW \('.'. lxxi\,~'\
Additional Optional Skills to be Demonstrated in Clinical
Anytime During or After Level 2
Intravenous and Vascular Access Therapy
Initiating intravenous therapy
3/ \II,'\ D
1- 1,- \C, r /28/19 0

3/\\,/~q D

,-\7 - A 1/zcal ,9 0

½hh9 D

Y/i/ 1u.. 0

~II/ l c... D

Y/1 fl~ 0

7. /1..; I IC\ D

2 /Y/19 0
Enteral Nutrition
Inserting and removing a small-bore nasogastric/nasoenteric
feeding tube D

0
Irrigating a feeding tube
D

0
Checking feeding tube residuals
D

u 0
STUDENT NAME:
Administering enteral nutrition: Nasoenteric, gastrostomy, or
jejunostomy tube

Ostomy Care
Pouching a colostomy or an ileostomy
D

0
Perioperative Care
Preparing a client for surgery
D

0
Wound Care
Performing a wound assessment
D

1l2<o/rct 0

0
Urinary Elimination
Insertion of a r ight or indwelling urinary catheter
D

0
~ NAME: ~G.rn,\e l,x')o.\((\\
~ -~~uired Level 3 Lab SkillS-*these skills must be signed off in lab
prior to demonstration in clinical
Medication Administration
*PBA - Medication Administration (Level 3)
~ {\I"\~\.:) vl.\:J C:>· lO ·l'\ D

t?. fYl ~ N d!.A.J () lr J-t) 0

Intravenous and Vascular Access Therapy
*PBA - Central line dressing change
D

0
Airway Management
*Performing tracheostomy c~ · V '-'7~v-,
D

0
Closed Chest Drainage Systems
m,/ - ·~ - ~~ . 7- 2- ,
*Managing closed-chest draina~e,_,,.
7 D

Specimen Collection
*Blood gl case monitoring *(Level 1 and 3)
D

Antepartu
*Ges

) , 5'---1)-L
D
0
* Fund us check \[___ ~/ \6/\°', D
~-- li / ('II)-( Y 17-l 0

r'Lo/h;,;;;p P(VV-L ) -; 7~{_1

D

0
STUDENT NAME:
*Perineum assessment

- /7- /
*Breast assessment
D

0
*Wound assessment
D

Newborn/Pediatric
*Newborn head to toe assessment
D

0
*Vital signs {TPR, BP, pain management, pulse oximetry)
D

0
*Weight and Height
D

/C.-- IV~ rNY-l S---17 - cCf/ 0

*Measurements {OFC , Chest circumference, abdominal girth)
D

0
*Gestational age assessment
D

0
* Reflex assessment
D

0
*Head-to-Toe assessment of pediatric client
D

0
 oENTNAME: ~0-rn,\e "00.\n::~
Optional Skills to be Demonstrated in Clinical Anytime
During or After Level 3

Oxygen Therapy
Administering oxygen to a client with an artificial airwa
-52-.~,, D

0
Care o echanical ventilator
D

0
Airway Management
Airway suctioning D
0
Performing endotracheal tube care D
0
Parenteral Nutrition
Administering parenteral nutrition through a central line D
8 \ 6 / 1'-\ 0
Administering parenteral nutrition through a peripheral line D
0
Newborn/Pediatric
tion to pediatric client - parenteral D
0
t ion to pediatric client - oral D
0

e 4 Lab SkillS-*these skills must be signed off in

stration in clinical
Medication Administration
*PBA - Medication Administration (Level 4) D
0
 STUDENT NAME:

~ f l , M - uLy ifm()rJ 69-v; t2AJ -

I~\'r\ 0 e_gli ~iZW
/J &uFJJlL e -~
r;x
- ~
rYl S NtfLrJ /o4 - -
V
Donna Carlson, MSN, RN c,

~ ~ /4) {35r,) xhkl!L- kib,/fY1J,

~~ &J.,o<AJ" JES~1'c;aA~\ ~~-s~
~r-TT,L,L✓,.>- >. A ~ £ A . J - ~ r 7 ~ ~ y M.f'A.;,b-1

f~~
,,
flu ,BsrJ - ~~<J,1... f-/-aA ne r f?,JJ,_& N

Ytlh M Mond rtftjin ~ i ff"

1

____,
· s~ Cl>OW'f\.,, & N 1 (2..N

~-.::::::- J{SS1C91 ~rvui liN,~r-{

~ o d -•o\oJ Bs\( e.,'t\ [0.~t,,+ lllx«::!1 f)'OO m-1 I f<'ill
~~,~~lh(\~